Invasive Systemic Infection After Hospital Treatment for Diabetic Foot Ulcer: Risk of Occurrence and Effect on Survival.

BACKGROUND: Diabetic foot ulcers (DFUs) threaten limbs and prompt hospitalization. After hospitalization, remote-site invasive systemic infection related to DFU (DFU-ISI) may occur. The characteristics of DFU-ISIs and their effect on mortality risk have not been defined. METHODS: We conducted a retrospective cohort study of 819 diabetic patients hospitalized for treatment of 1212 unique DFUs during a 9-year period. We defined the index ulcer as that present at the first (index) DFU admission to our hospital. We defined DFU-ISI as a nonfoot infection that occurred after the index hospitalization and was caused by a microorganism concomitantly or previously cultured from the index ulcer. We determined the frequency, risk factors, and mortality risk associated with DFU-ISIs. RESULTS: After 1212 index DFU hospitalizations, 141 patients had 172 DFU-ISIs. Of the initial 141 DFU-ISIs, 64% were bacteremia, 13% deep abscesses, 10% pneumonia, 7% endocarditis, and 6% skeletal infections. Methicillin-resistant Staphylococcus aureus (MRSA) caused 57% of the ISIs. Patients with initial DFU cultures yielding MRSA and protracted open ulcers had a high 24-month cumulative probability of DFU-ISI (31%) and all-cause mortality rate (13%). Analysis with Cox regression modeling showed that complicated ulcer healing (hazard ratio, 3.812; 95% confidence interval, 2.434-5.971) and initial DFU culture yielding MRSA (2.030; 1.452-2.838) predicted DFU-ISIs and that DFU-ISIs were associated with increased mortality risk (1.987; 1.106-3.568). CONCLUSIONS: DFU-ISIs are important late complications of DFUs. Prevention of DFU-ISIs should be studied prospectively. Meanwhile, clinicians should aggressively incorporate treatment to accelerate ulcer healing and address MRSA into the care of diabetic patients with foot ulcers.

Pristinamycin in the treatment of MSSA bone and joint infection.

OBJECTIVES: The aim of this study was to evaluate pristinamycin in the treatment of MSSA bone and joint infection (BJI). PATIENTS AND METHODS: A retrospective, single-centre cohort study (2001-11) investigated outcome in adults receiving pristinamycin for MSSA BJI and pristinamycin-related adverse events (AEs). RESULTS: One hundred and two MSSA BJIs were assessed in 98 patients [chronic infection, 33.3%; and orthopaedic device-related infection (ODI), 67.6%]. Surgery was performed in 77.5% of total cases, and in all but three ODIs, associated with antibiotic therapy of a median total duration of 29.2 weeks. Pristinamycin was prescribed as a part of the initial intensive treatment phase (29.4%) and/or included in final maintenance therapy (83.3%) at a dose of 47.6 (45.5-52.6) mg/kg/day for 9.3 (1.4-20.4) weeks. AEs occurred in 13.3% of patients, consisting of gastrointestinal disorder (76.9%) or allergic reaction (23.1%), leading to treatment interruption in 11 cases. AEs were related to daily dose (OR, 2.733 for each 10 additional mg/kg/day; P = 0.049). After a follow-up of 76.4 (29.6-146.9) weeks, the failure rate was 34.3%, associated with ODI (OR, 4.421; P = 0.006), particularly when the implant was retained (OR, 4.217; P = 0.007). In most patients, the pristinamycin companion drug was a fluoroquinolone (68.7%) or rifampicin (21.7%), without difference regarding outcome. CONCLUSIONS: Pristinamycin is an effective, well-tolerated alternative therapeutic option in MSSA BJI, on condition that a daily dosage of 50 mg/kg is respected.

Local control of rhino-orbito-cerebral mucormycosis dramatically impacts survival.

Surgery and antifungals are the reference standard for rhino-orbito-cerebral mucormycosis (ROCM) treatment. The impact of local control on survival of 22 consecutive ROCM adults was studied on day 90: none vs. 75% died, respectively, with or without local control (p <0.0001). Hence, repeated surgical procedures are recommended to achieve local control of ROCM.

The value of successive Infecton scans in assessing the presence of chronic bone and joint infection and in predicting its evolution after treatment and after a prolonged follow-up.

OBJECTIVE: Our objective was to monitor the evolution of bone and/or joint infections with the aid of successive radiolabelled ciprofloxacin (Infecton) scans during antimicrobial treatment and to compare the results of an Infecton scan at the end of therapy with the respective results of clinical evaluation, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in predicting resolution or recurrence of infection after a long period of posttreatment follow-up. METHODS: Thirty-three patients with documented bone and/or joint infection were subjected to successive Infecton scans on two or three visits. Infecton scans were evaluated visually and scored accordingly. Clinical evaluation was scored by the referring clinicians. ESR and CRP values were evaluated independently. A minimum of 2-year free-of-infection follow-up after discontinuation of the antibiotic treatment served as a measure of successful antimicrobial therapy and nonrecurrence of infection. Statistics included survival analysis (Cox regression). RESULTS: During follow-up, five patients in the study presented with recurrence, and three died as a result of an irrelevant cause. The remaining patients were followed up for a median of 108 months (range 97-132 months) without any signs of recurrence of infection. Recurrence of infection was 4.2 times more likely to occur in patients with positive Infecton scans [hazard ratio (HR): 4.2, confidence intervals 95%: 1.39-12.67, P=0.011]. Infecton had the highest sensitivity (83.3%), accuracy (69.69%) and negative predictive value (94.74%), whereas CRP had the highest specificity (76.92%). CONCLUSION: Infecton scintigraphy proved to be more sensitive and accurate and had a higher negative predictive value compared with clinical evaluation, ESR and CRP in predicting infection resolution or recurrence in patients with chronic bone and joint infections.